Healthcare Provider Details

I. General information

NPI: 1659763621
Provider Name (Legal Business Name): SHANNON HEILING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MCMILLAN RD
DACULA GA
30019-2337
US

IV. Provider business mailing address

256 MCMILLAN RD
DACULA GA
30019-2337
US

V. Phone/Fax

Practice location:
  • Phone: 770-545-6368
  • Fax:
Mailing address:
  • Phone: 770-545-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10911
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: